Understanding trends and variation in paediatric fracture management in England

Sarah Lucas

23 September 2024

Background (continued)

Epidemiology of paediatric fractures

One hospital in Ireland calculated a paediatric fracture incidence rate of approximately 29 fractures/1,000/year1. The most common fracture was distal radial/buckle fractures (27.2%), followed by distal humerus /supracondylar fracture (13.9%), ankle fractures (9.2%), phalanx fractures (8.3%), and radial/ulnar metaphysis fractures (5.7%). It is suggested the incidence rate will depend on the social emphasis on encouraging physical activity1.

Between 2012–2019, 368,120 children under 18 were admitted to English NHS hospitals with a fracture; 256,008 (69.5%) were upper limb and 85,737 (23.3%) were lower limb fractures2. The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100 000 children).

Paediatric fracture management

British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement3.

The FORCE study found in children with a torus fracture of the distal radius there was no difference in outcomes between those who were offered of a bandage and immediate discharge (as per UK National Institute for Health and Clinical Excellence recommendations) and those receiving current treatment of rigid immobilisation and follow-up4.

One study in Scotland found that uncomplicated paediatric clavicle fractures can be managed without x-rays in the ED as they do not influence fracture management or add valuable information to clinicians’ assessment5.


  1. Baig MN. (2017) A Review of Epidemiological Distribution of Different Types of Fractures in Paediatric Age. Cureus. 28;9(8):e1624
  2. Marson BA et al. (2021) Trends in hospital admissions for childhood fractures in England. BMJ Paediatr Open. 10;5(1):e001187
  3. Modifiable Templates for Management of Common Fractures. https://www.bscos.org.uk/public/resources.
  4. Perry DC et al. (2022). Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet; 400(10345):39-47
  5. Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304.

Background (continued)

Manipulation of paediatric fractures

A GIRFT report on Paediatric Trauma and Orthopaedic Surgery found that over 250 weeks of operating time a year had been dedicated to manipulation of the forearm and wrist between 2016 and 20191. A significant proportion of these displaced or angulated wrist fractures could have been manipulated and cast in the emergency department rather than being admitted and treated in the operating theatre. The GIRFT report found significant variation between trusts in the number of manipulating being performed in theatre. If the number of fractures manipulated in theatre was reduced to the level in trusts with well-developed ED manipulation protocols, there would be an 80% reduction in manipulations in theatre, reducing theatre time for forearm/wrist fractures to 57 weeks or less.

Due to pressures on hospitals from the COVID-19 pandemic the British Orthopaedic Association developed guidelines for the early management of distal forearm fractures in children. A study conducted at one trust found following the implementation of these guidelines resulted in 86% of distal forearm fractures in children were manipulated in the ED, an increase from 32% prior to the COVID pandemic2. This saved approximately 63 hours of theatre time in the six-month study period.

The GIRFT report highlighted reluctance to perform procedures in the emergency department because of worries about breach times, a lack of space/facilities to perform sedation and a lack of familiarity with techniques1.




  1. Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
  2. Fink BE etal (2023) Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines. Cureus. 15(7):e41325.

Aims


  1. Update and add to the information in the literature on the epidemiology/incidence rate of various paediatric fractures (toe, clavicle, wrist and elbow) in England.

  2. Understand the trends in management of these fracture types over time, e.g. have changes in guidance during COVID-19 changed the trends in management of fractures in Emergency departments.

  3. Investigate the variation in management of these fracture types between trusts, and the potential activity and cost savings if there was more widespread conservative management, such as reducing unnecessary follow-ups appointments and manipulation in the Emergency Department rather than in theatre.

Data sources and Study population

Data were taken from the Emergency care dataset (ECDS) and linked with records in the Outpatient and Admitted Patient Care Episode (APCE) datasets, all accessed through the National Commissioning Data Repository (NCDR).

The study population included all those aged 16 and under that attended an emergency care centre and had a SNOMED code for closed fractures of toe, clavicle, elbow or wrist recorded (see Appendices A-C for full code lists) in England between April 2018 and March 2024.

This study focuses on closed fractures as this is where there is scope for more conservative management; open, pathological, osteoporotic and birth trauma fractures have been excluded, alongside fractures of the great toe which should all be followed up.

Incidence rates were calculated using the Office of National Statistics (ONS) mid-year population estimates of those aged 16 years and under1.

The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. However, we could calculate the proportion of children with each fracture type that:

  • received a follow-up appointment
  • had a fracture manipulated in theatre (only includes closed manipulations and not re-manipulations)
  • had a fracture manipulated in the emergency department
  • had a referral/appointment for physiotherapy
  • had an X-ray in the emergency department

Full details of the coding used to identify these procedures/attendances is included in Appendix D.

  1. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorthernireland

Characteristics of the cohort

 

Clavicle
(N=85,060)

Elbow
(N=120,943)

Forearm
(N=399,469)

Tibia/Fibula
(N=75,462)

Toe
(N=80,590)

Overall
(N=761,524)

Sex

  Female

26,133 (30.7%)

55,231 (45.7%)

155,681 (39.0%)

30,504 (40.4%)

32,924 (40.9%)

300,473 (39.5%)

  Male

58,735 (69.1%)

65,444 (54.1%)

242,918 (60.8%)

44,785 (59.3%)

47,539 (59.0%)

459,421 (60.3%)

  Missing/Unknown

192 (0.2%)

268 (0.2%)

870 (0.2%)

173 (0.2%)

127 (0.2%)

1,630 (0.2%)

Age

  0-4 yrs

23,108 (27.2%)

30,405 (25.1%)

50,685 (12.7%)

34,192 (45.3%)

3,916 (4.9%)

142,306 (18.7%)

  5-10 yrs

25,809 (30.3%)

59,063 (48.8%)

186,458 (46.7%)

16,173 (21.4%)

28,951 (35.9%)

316,454 (41.6%)

  11-16 yrs

36,143 (42.5%)

31,475 (26.0%)

162,326 (40.6%)

25,097 (33.3%)

47,723 (59.2%)

302,764 (39.8%)

Ethnicity

  Asian or Asian British

4,437 (5.2%)

10,589 (8.8%)

25,180 (6.3%)

5,063 (6.7%)

5,042 (6.3%)

50,311 (6.6%)

  Black or Black British

1,965 (2.3%)

2,546 (2.1%)

8,337 (2.1%)

2,400 (3.2%)

2,024 (2.5%)

17,272 (2.3%)

  Mixed

2,645 (3.1%)

4,194 (3.5%)

12,178 (3.0%)

2,838 (3.8%)

2,538 (3.1%)

24,393 (3.2%)

  Other Ethnic Groups

2,334 (2.7%)

3,420 (2.8%)

11,089 (2.8%)

2,387 (3.2%)

2,052 (2.5%)

21,282 (2.8%)

  White

65,499 (77.0%)

89,109 (73.7%)

305,673 (76.5%)

55,781 (73.9%)

61,388 (76.2%)

577,450 (75.8%)

  Missing/Unknown

8,180 (9.6%)

11,085 (9.2%)

37,012 (9.3%)

6,993 (9.3%)

7,546 (9.4%)

70,816 (9.3%)

IMD Quintiles

  1

18,694 (22.0%)

30,818 (25.5%)

93,220 (23.3%)

19,160 (25.4%)

18,685 (23.2%)

180,577 (23.7%)

  2

15,829 (18.6%)

23,744 (19.6%)

77,000 (19.3%)

14,899 (19.7%)

15,425 (19.1%)

146,897 (19.3%)

  3

16,079 (18.9%)

22,125 (18.3%)

74,179 (18.6%)

13,628 (18.1%)

15,020 (18.6%)

141,031 (18.5%)

  4

16,524 (19.4%)

21,601 (17.9%)

74,494 (18.6%)

13,537 (17.9%)

15,050 (18.7%)

141,206 (18.5%)

  5

17,058 (20.1%)

21,426 (17.7%)

76,790 (19.2%)

13,492 (17.9%)

15,758 (19.6%)

144,524 (19.0%)

  Missing/Outside England

876 (1.0%)

1,229 (1.0%)

3,786 (0.9%)

746 (1.0%)

652 (0.8%)

7,289 (1.0%)

Emergency Dept type

  Major Emergency Dept

67,903 (79.8%)

96,949 (80.2%)

304,781 (76.3%)

63,701 (84.4%)

53,158 (66.0%)

586,492 (77.0%)

  Urgent Treatment Centre/Walk in centre

17,149 (20.2%)

23,987 (19.8%)

94,645 (23.7%)

11,743 (15.6%)

27,430 (34.0%)

174,954 (23.0%)

  Mono-specialty Emergency Dept

0 (0%)

0 (0%)

1 (0.0%)

2 (0.0%)

0 (0%)

3 (0.0%)

  Same Day Emergency Care

8 (0.0%)

7 (0.0%)

42 (0.0%)

16 (0.0%)

2 (0.0%)

75 (0.0%)

Day of ED attendance

  Weekday

59,144 (69.5%)

86,766 (71.7%)

290,942 (72.8%)

53,124 (70.4%)

59,828 (74.2%)

549,804 (72.2%)

  Weekend

25,916 (30.5%)

34,177 (28.3%)

108,527 (27.2%)

22,338 (29.6%)

20,762 (25.8%)

211,720 (27.8%)

Time of ED attendance

   Daytime 7am to 7pm

72,998 (85.8%)

101,404 (83.8%)

346,680 (86.8%)

64,593 (85.6%)

70,489 (87.5%)

656,164 (86.2%)

  Nighttime 7pm to 7am

12,062 (14.2%)

19,539 (16.2%)

52,789 (13.2%)

10,869 (14.4%)

10,101 (12.5%)

105,360 (13.8%)

Year of ED attendance

  2018/19

11,757 (13.8%)

16,985 (14.0%)

51,997 (13.0%)

10,094 (13.4%)

10,793 (13.4%)

101,626 (13.3%)

  2019/20

14,565 (17.1%)

21,103 (17.4%)

66,577 (16.7%)

12,711 (16.8%)

14,953 (18.6%)

129,909 (17.1%)

  2020/21

11,612 (13.7%)

16,942 (14.0%)

56,492 (14.1%)

10,719 (14.2%)

9,969 (12.4%)

105,734 (13.9%)

  2021/22

16,739 (19.7%)

21,943 (18.1%)

82,556 (20.7%)

14,190 (18.8%)

15,034 (18.7%)

150,462 (19.8%)

  2022/23

15,119 (17.8%)

21,840 (18.1%)

71,844 (18.0%)

13,740 (18.2%)

14,604 (18.1%)

137,147 (18.0%)

  2023/24

15,268 (17.9%)

22,130 (18.3%)

70,003 (17.5%)

14,008 (18.6%)

15,237 (18.9%)

136,646 (17.9%)

Fracture incidence rates for England (2023/2024)


Annual fracture incidence rates per 100,000 children (0-16yrs)

Type

Female
0-4 yrs

Female
11-16 yrs

Female
5-10 yrs

Male
0-4 yrs

Male
11-16 yrs

Male
5-10 yrs

Total

Clavicle

131

62

77

131

250

154

136

Elbow

172

95

284

175

174

271

197

Forearm

270

362

786

273

1,024

828

622

Tibia/Fibula

174

71

72

213

171

76

124

Toe

17

160

125

26

281

142

135


Forearm/wrist fractures are the most common followed by elbow fractures.

Incidence rate by age/sex group

Denominator for calculating incidence rate is the number of children of that age and sex in England, e.g. incidence per 100,000 0-4 yr old males


Tibia/Fibula fractures are most common in those aged 0-4 years

Elbow fractures are most common in those aged 5-10 years

In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 yrs old having the highest incidence of clavicle, forearm and toe fractures.

Most common fracture types (2023/2024)


SNOMED description

Number

Percentage

Closed fracture of radius (disorder)

Forearm

48,043

35.2

Elbow fracture - closed (disorder)

Elbow

18,613

13.6

Closed fracture of radius AND ulna (disorder)

Forearm

17,498

12.8

Closed fracture of clavicle

Clavicle

15,259

11.2

Closed fracture of phalanx of foot (disorder)

Toe

15,232

11.1

Closed fracture of tibia (disorder)

Tibia/Fibula

8,549

6.3

Closed fracture of ulna (disorder)

Forearm

4,347

3.2

Closed supracondylar fracture of humerus (disorder)

Elbow

3,394

2.5

Closed fracture of fibula (disorder)

Tibia/Fibula

3,278

2.4

Closed fracture of tibia AND fibula (disorder)

Tibia/Fibula

2,145

1.6

Closed Monteggia's fracture (disorder)

Elbow

108

0.1

Closed Galeazzi fracture (disorder)

Forearm

65

0.0

Closed fracture of distal end of radius (disorder)

Forearm

23

0.0

Only showing those fracture types recorded 10 or more times


The majority of fractures are recorded within the emergency care dataset under just a few snomed codes.

There are codes available that specify whether a radius fracture is proximal or distal, but these are not used, instead the general code ‘Closed fracture of radius (disorder)’ is used. We have classified this as a forearm fracture but some of these fractures might be proximal radius and more accurately classified at elbow fractures.

Fractures of great toe was excluded as these should be followed up, however <10 codes related to the fracture of the great toe were recorded over the whole 6 yr period in England, suggesting that many of great toe fractures may be coded as ‘Closed fracture of phalanx of foot (disorder)’ and thus included within our dataset.

Incidence of upper limb fractures by ICB (2023/2024)

Incidence of lower limb fractures by ICB (2023/2024)

Incidence rates are based on the number of attendances within the ICB area, regardless of whether those attending are resident in the area, relative to the resident population.

For all fracture types the incidence rates are high in the Cornwall and Isles of Scilly ICB area.

There are also generally high rates of several fracture types in the Gloucester ICB, Shropshire, Telford and Wrekin ICB and Hereford and Worcestershire ICB areas. In these areas it is possible the higher incidence rates may at least in part be due to those living in Wales accessing emergency care centres in these areas.

The fracture incidence rate is generally lowest is the South East of England, particularly in the London area.

Table of incidence rates per 100,000 by ICB (2023/2024)

ICB

Clavicle

Elbow

Forearm

Tibia/Fibula

Toe

Total

NHS Cornwall and the Isles of Scilly Integrated Care Board

220

365

1,136

177

262

2,159

NHS Herefordshire and Worcestershire Integrated Care Board

201

308

1,016

142

269

1,934

NHS Shropshire, Telford and Wrekin Integrated Care Board

215

292

971

139

230

1,847

NHS Gloucestershire Integrated Care Board

222

186

1,004

183

205

1,800

NHS Derby and Derbyshire Integrated Care Board

185

256

905

169

232

1,747

NHS Somerset Integrated Care Board

195

280

925

150

190

1,740

NHS Dorset Integrated Care Board

188

280

857

145

194

1,664

NHS South Yorkshire Integrated Care Board

192

305

803

169

193

1,662

NHS Norfolk and Waveney Integrated Care Board

198

281

842

167

165

1,653

NHS Devon Integrated Care Board

188

262

871

163

150

1,634

NHS Black Country Integrated Care Board

164

304

818

148

144

1,578

NHS Sussex Integrated Care Board

162

241

825

128

171

1,528

NHS North East and North Cumbria Integrated Care Board

146

232

748

148

186

1,460

NHS Humber and North Yorkshire Integrated Care Board

187

213

727

136

162

1,425

NHS Lincolnshire Integrated Care Board

146

214

736

134

187

1,417

NHS Coventry and Warwickshire Integrated Care Board

174

189

717

146

149

1,375

NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board

132

246

688

110

146

1,322

NHS Greater Manchester Integrated Care Board

140

196

708

114

164

1,322

NHS Mid and South Essex Integrated Care Board

138

215

660

163

137

1,312

NHS Cheshire and Merseyside Integrated Care Board

150

221

661

139

141

1,311

NHS Hampshire and Isle of Wight Integrated Care Board

134

231

638

139

125

1,267

NHS West Yorkshire Integrated Care Board

156

200

621

132

133

1,243

NHS Birmingham and Solihull Integrated Care Board

127

236

603

123

142

1,232

NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board

125

226

589

177

91

1,208

NHS Nottingham and Nottinghamshire Integrated Care Board

131

216

597

150

114

1,208

NHS Northamptonshire Integrated Care Board

144

202

578

97

118

1,139

NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board

145

191

571

116

94

1,117

NHS South West London Integrated Care Board

130

111

569

149

141

1,101

NHS Cambridgeshire and Peterborough Integrated Care Board

146

179

550

99

120

1,094

NHS Suffolk and North East Essex Integrated Care Board

145

157

523

106

129

1,060

NHS Lancashire and South Cumbria Integrated Care Board

122

170

530

124

107

1,052

NHS Hertfordshire and West Essex Integrated Care Board

110

150

506

100

113

980

NHS Surrey Heartlands Integrated Care Board

130

162

460

102

115

970

NHS Leicester, Leicestershire and Rutland Integrated Care Board

99

168

446

128

94

934

NHS Staffordshire and Stoke-on-Trent Integrated Care Board

87

121

503

88

125

923

NHS North Central London Integrated Care Board

92

135

438

107

92

864

NHS Kent and Medway Integrated Care Board

85

104

440

63

109

801

NHS North West London Integrated Care Board

82

132

393

88

74

770

NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board

84

116

356

78

55

689

NHS Frimley Integrated Care Board

70

118

327

77

46

639

NHS South East London Integrated Care Board

62

103

293

72

69

598

NHS North East London Integrated Care Board

59

121

276

80

47

584

Proportion of ED attendances with a fracture code (2022/2023)

Number of fractures per 10,000 emergency care attendances in those age 16 or under for each provider.

There is considerable variability between providers in the number fractures seen per 10,000 emergency care attendances.

These differences could be due to:

  • Alternative provision locally e.g. very few children attend the Royal Liverpool hospital with fractures as it is located close to Alder Hey, a specialist paediatric centre. Or an independent urgent care provision available locally.

  • Difference in fracture rates in different areas e.g. higher rates in Cornwall and generally lower rate in the London area, which may be related levels of physical activity/visitors from out of area.

  • Coding/reporting issues resulting in not all fractures being recorded in the emergency departments.

Summary of analysis of incidence rates

  • In children forearm fractures are the most common followed by elbow fractures.

  • Fractures of tibia/fibula are most common in under 5, and elbow fractures are most common in 5-10 yr olds. For older children the fracture rate is higher in boys compared to girls, with boys aged 11-16 yrs having the highest rates of clavicle, forearm and toe fractures.

  • There is significant seasonality with much higher fractures rates seen in the summer months, likely related to increased outdoor physical activity.

  • Fracture incidence rates vary considerably by ICB region, with high incidence rates in Cornwall and lower rates in London areas. Incidence rates also vary considerable by trust. It is possible some of these differences could be due to issues with coding and reporting of fractures. However, some of the differences are likely related to availablity of alternative provision locally (specialist paediatric centre or independent urgent treatment centre nearby) or due to differences in fracture rates related to different levels of physical activity.

  • Lack of detailed coding of fractures means some fractures may be misclassified, e.g. it is not possible to determine which radius fractures may be more accurately classified as elbow rather than wrist/forearm fractures, and great toe fractures are not specifically recorded.

Percentage of fractures with a follow-up appointment


There is a trend towards a reduction in the proportion of emergency department attendances for upper limb fractures where a follow-up appointment is given.

Proportion of face-to-face vs virtual follow-up appointments


As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face-to-face has fallen significantly.

Only showing data for the first outpatient attendance

Proportion of follow-up outpatient appt with/without procedure recorded


Over the last 6 yrs the proportion of patients with a fracture that have a follow-up outpatient appointment where a procedure is recorded has decreased, especially following COVID-19.

The proportion of patients with a follow-up outpatient appointment with no procedures recorded has remained relatively stable over time. Although for tibia/fibula and elbow fractures there was a slight increase in the proportion of these follow-ups at the start of the pandemic which has remained in the post-pandemic.

Only showing data for the first outpatient attendance

Outpatient procedures recorded following ED attendance

When children are given a follow-up outpatient appointment following an emergency department attendance for a a fracture it is common to have more than one procedure recorded.

The majority of procedures are related to casts/bandages/splints, and the numbers of these have decreased post-pandemic, as has the number of diagnostic imaging procedures during follow-up appointment. This likely indicates a move towards more conservative management of fractures especially with an increasing proportion of follow-ups being conducted virtually.

There are also some procedures of joint (OPCS code W92) recorded in outpatient follow-up appointments following a fracture (this code includes: distension of joint, examination of joint including under image intensifier or anaesthetic, chemical or radiation synovectomy)

The number of manipulations recorded during outpatient appointments is extremely small.

Only showing data for the first outpatient attendance and the most common types of procedures

Number of follow-up appointments (2022/23)

Includes all outpatient attendances including physiotherapy appointments, which were attended, in the 3 months post-fracture.

Percentage of fractures manipulated in the ED


The percentage of forearm fractures manipulated in the emergency department has increased over the last 6 yrs, with a large increase seen during the COVID-19 pandemic. There is also a noticeable seasonal trend with a greater percentage of fractures manipulated in the emergency department during the summer months.

The percentage of tibia/fibula fractures manipulated in the emergency department has also increased, but there is little change in the other fracture types over time.

Percentage of fractures manipulated in theatre


The percentage of forearm fractures manipulated in theatre has decreased significantly over the last 6 yrs, with a greater percentage of fractures manipulated in theatre during the summer months.

The percentage of tibia/fibula fractures manipulated in theatre as also decreased.

Proportion of fractures manipulated in ED vs theatre

Over the last 6 years the proportion of manipulations in theatre compared to the emergency department has decreased mostly notably for forearm fractures where currently over half of all manipulations are performed in the emergency department.

There does appear to be a decrease in the total number of fractures being manipulated either in ED or theatre, especially for forearm fractures.

Percentage of fractures referred for physiotherapy


The percentage of fractures with a referral/outpatient attendance for physiotherapy in the 3-months post-fractures are higher for those with elbow and tibia/fibula fractures, but generally very low for the other fracture types.

The proportion of elbow fractures referred to physiotherapy has decreased over the last 6 years, while the proportion of tibia/fibula fractures referred has increased.

Percentage of fractures with a X-ray recorded in the ED


The majority of fractures of all types are x-rayed in the emergency department, although the percentage of toe fractures x-rayed is slightly lower.

Use of emergency depts vs urgent treatment/walk-in centres


There is a trend towards a greater proportion of fractures being seen in urgent treatment/ walk-in centres rather than emergency departments.

It could be hypothesised that if the proportion of fractures seen in the emergency department continues to decrease that the opportunities to increase manipulations of fractures in the emergency department could become more limited over time.

Manipulations, following ED or UTC attendance (2022/23)

As would be expected those attending emergency departments rather than urgent treatment centres are more likely to have there fractures manipulated in the emergency department.

However, the percentage of fractures manipulated in theatre is also higher for those attending emergency departments, suggesting those with more obvious/complex fractures that require manipulation are more likely to attend emergency departments, or be sent there from urgent treatment centres (in a small number of cases where a child attended 2 emergency care sites on the same day, we have only included the second attendance).



In 2022/23, 73% of fractures were seen in the emergency department, and 27% in urgent treatment centres.

However, 90% of fractures requiring manipulations were seen in the emergency department and around 10% in urgent treatment centres, further indicating that those with fractures that require manipulation are more likely to attend an emergency department rather than an urgent treatment centre.

:::

Follow-ups given in ED vs Urgent treatment centres (2022/23)

The percentage of fractures where a follow-up appointment is given is broadly similar at urgent treatment centres and emergency departments.

Factors influencing whether a follow-up appointment is given

Odds Ratio

Confidence Intervals

P value

(Intercept)

2.40

2.34 to 2.45

<0.001*

Sex

Female

1.00

Reference

Male

1.12

1.11 to 1.13

<0.001*

Age

5-10 yrs

1.00

Reference

0-4 yrs

0.95

0.94 to 0.97

<0.001*

11-16 yrs

1.15

1.13 to 1.16

<0.001*

Ethnicity

White

1.00

Reference

Asian or Asian British

1.05

1.03 to 1.07

<0.001*

Black or Black British

1.15

1.11 to 1.19

<0.001*

Mixed

1.03

1 to 1.06

0.06

Other Ethnic Groups

1.01

0.98 to 1.05

0.36

Missing/Unknown

0.97

0.95 to 0.99

<0.001*

IMD Quintiles

1

1.00

Reference

2

1.10

1.08 to 1.11

<0.001*

3

1.03

1.02 to 1.05

<0.001*

4

1.06

1.04 to 1.08

<0.001*

5

1.09

1.08 to 1.11

<0.001*

Department type

Major Emergency Department

1.00

Reference

Urgent Treatment Centre/Walk in centre

0.94

0.93 to 0.95

<0.001*

Day of the week

Week

1.00

Reference

Weekend

1.07

1.06 to 1.08

<0.001*

Time of day

Day 7am-7pm

1.00

Reference

Night 7pm to 7am

1.12

1.1 to 1.14

<0.001*

Time of year

Autumn

1.00

Reference

Winter

0.95

0.93 to 0.96

<0.001*

Spring

0.95

0.94 to 0.97

<0.001*

Summer

0.99

0.97 to 1

0.05

Year

2018/19

1.00

Reference

2019/20

0.92

0.9 to 0.94

<0.001*

2020/21

0.78

0.76 to 0.79

<0.001*

2021/22

0.72

0.71 to 0.73

<0.001*

2022/23

0.66

0.65 to 0.67

<0.001*

2023/24

0.66

0.65 to 0.67

<0.001*

Fracture type

Forearm

1.00

Reference

Clavicle

0.79

0.77 to 0.8

<0.001*

Elbow

2.50

2.46 to 2.55

<0.001*

Tibia/Fibula

2.04

2 to 2.08

<0.001*

Toe

0.36

0.35 to 0.36

<0.001*

Children are more likely to be given a follow-up appointment if they are

  • male

  • 11-16 yrs old

  • from an asian or black background

  • are not living in an area in the most deprived quintile

They are also more likely to have a follow-up appointment if they attended

  • an emergency department

  • on a weekend

  • at nighttime

Those attending in more recent years were less likely to have a follow-up appointment, further indicating there has been a move towards fewer follow-up appointments.

Factors influencing manipulation of forearm fractures in theatre

Odds Ratio

Confidence Intervals

P value

(Intercept)

8.10

7.26 to 9.05

<0.001*

Sex

Female

1.00

Reference

Male

0.91

0.86 to 0.96

<0.001*

Age

5-10 yrs

1.00

Reference

0-4 yrs

1.62

1.49 to 1.76

<0.001*

11-16 yrs

0.51

0.49 to 0.54

<0.001*

Ethnicity

White

1.00

Reference

Asian or Asian British

0.80

0.72 to 0.89

<0.001*

Black or Black British

0.52

0.44 to 0.62

<0.001*

Mixed

0.69

0.61 to 0.79

<0.001*

Other Ethnic Groups

0.54

0.47 to 0.63

<0.001*

Missing/Unknown

0.84

0.77 to 0.91

<0.001*

IMD Quintiles

1

1.00

Reference

2

0.77

0.71 to 0.83

<0.001*

3

0.73

0.68 to 0.79

<0.001*

4

0.70

0.65 to 0.76

<0.001*

5

0.65

0.6 to 0.7

<0.001*

Department type

Major Emergency Department

1.00

Reference

Urgent Treatment Centre/Walk in centre

5.15

4.62 to 5.76

<0.001*

Day of the week

Week

1.00

Reference

Weekend

1.09

1.04 to 1.15

<0.001*

Time of day

Day 7am-7pm

1.00

Reference

Night 7pm to 7am

1.12

1.05 to 1.2

<0.001*

Time of year

Autumn

1.00

Reference

Winter

0.83

0.77 to 0.91

<0.001*

Spring

1.06

0.99 to 1.13

0.08

Summer

1.16

1.09 to 1.23

<0.001*

Year

2018/19

1.00

Reference

2019/20

0.72

0.66 to 0.8

<0.001*

2020/21

0.31

0.28 to 0.34

<0.001*

2021/22

0.30

0.27 to 0.33

<0.001*

2022/23

0.20

0.18 to 0.22

<0.001*

2023/24

0.14

0.13 to 0.16

<0.001*

Includes only forearm fractures that are manipulated, either the emergency department or in theatre (excludes those where manipulation is recorded in both ED and theatre) to determine what factors might be influencing the decision to manipulate a fracture in theatre rather than in the emergency department.

Children are more likely to have a fracture manipulated in theatre if they are

  • female

  • under the age of 5

  • white

  • from an area in the most deprived quintile

They are also more likely to have a manipulation in theatre if they attended

  • an urgent treatment centre

  • on a weekend

  • at nighttime

  • in the summer

Those attending in more recent years were less likely to have their fracture manipulated in theatre, further indicating there has been a move towards manipulating more fractures in the emergency department.

Summary of management of fractures

  • For upper limb fractures there has been a slight reduction in the number given a follow up appointment. For all fracture types there there has been a significant increase in the proportion of follow-up appointments conducted virtually since the pandemic.
  • Those presenting at night and at weekends were more likely to have follow up appointments and have their fracture manipulated in theatre. While it may be that those with more obviously/complex fractures that require manipulation/follow-up are more likely to present at these times, rather than perhaps waiting until the next day, it is likely also the result of less senior staff available at these times.
  • There has been a decrease post-pandemic in the number of outpatient procedures involving casts/splints/bandages and a decrease in diagnostic imaging in outpatients.
  • Over the last 6 years the proportion of fractures manipulated in theatre has decreased and the proportion manipulated in the emergency department has increased.
  • Those attending urgent treatment centres are more likely to have their fractures manipulated in theatre as this would generally not be possible at an urgent treatment centre. There is a trend for more fractures to be seen in urgent treatment centres, and while it appears that most of the fractures requiring manipulation are seen in ED rather than UTCs, a continued trend to seeing more fractures in UTCs may in the future impact the ability of trusts to further move away from manipulations in theatre.
  • The overall manipulation rate for forearm fractures has reduced over the last 6 years, which likely reflects a change in the culture, with displaced fractures now less likely to be manipulated. Indeed, the CRAFFT study is currently looking at whether there is a difference in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children1.
  • Overall, there is a trend towards more conservative management of paediatric fractures.
  1. www.CRAFFTstudy.org

Calculating proportions by trust

Includes only NHS trusts with 120+ attendances for fractures 2022/23; this resulted in 8 trusts being excluded. Some trusts may have low numbers due to alternative provisions locally e.g. Royal Liverpool had small numbers which is unsurprising given its proximity to a specialist paediatric provision at Alder Hey. Independent providers were also excluded, the majority of these had small numbers of attendances for fractures, i.e. <120 per year.


Overall numbers and percentages for 2022/2023

No. of fractures

X-ray in ED

Follow-up

Follow-up without procedure

Follow-up with procedure

Manipulated in theatre

Manipulated in ED

Manipulated in ED & theatre

Clavicle

15,119

13,149 (87%)

9,171 (60.7%)

8,388 (55.5%)

783 (5.2%)

8 (0.1%)

10 (0.1%)

0 (0%)

Elbow

21,840

19,193 (87.9%)

17,704 (81.1%)

13,658 (62.5%)

4,046 (18.5%)

258 (1.2%)

177 (0.8%)

12 (0.1%)

Forearm

71,844

62,679 (87.2%)

46,217 (64.3%)

35,550 (49.5%)

10,667 (14.8%)

3,024 (4.2%)

2,686 (3.7%)

222 (0.3%)

Tibia/Fibula

13,740

11,709 (85.2%)

10,896 (79.3%)

8,153 (59.3%)

2,743 (20%)

317 (2.3%)

140 (1%)

26 (0.2%)

Toe

14,604

11,117 (76.1%)

6,406 (43.9%)

5,830 (39.9%)

576 (3.9%)

9 (0.1%)

177 (1.2%)

1 (0%)

When considering potential savings in terms of follow-up appointments, we have considered all follow-up appointments (with and without procedures).

X-rays for Clavicle and Toes fractures by trust

Evidence suggests that x-raying the majority of clavicles and toes in the emergency department is unnecessary, as it doesn’t add useful information to a clinician’s assessment or alter management.

Percentage of clavicle fractures x-rayed

Min

5.9 %

1st quartile

87.7 %

Median

93.2 %

3rd quartile

95.7 %

Max

100 %

If all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (77.3%) there would be an annual reduction in England of 1,986 (15.5%) x-rays in emergency care.

Percentage of toe fractures x-rayed

Min

2.4 %

1st quartile

72.6 %

Median

82.4 %

3rd quartile

89.7 %

Max

100 %

If all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (62.3%) there would be an annual reduction in England of 2,412 (22.5%) x-rays in emergency care.

Cost of x-raying clavicle and toe fractures

Clavicle fracture

Toe fractures

All attendances at urgent treatment centres are costed at £85 regardless on whether a fracture is x-rayed.

For both clavicle and toe fractures without an x-ray the median cost of an emergency department attendance is £126 compared to a median cost of £184 when the fracture is x-rayed, suggesting a saving of £58 for each clavicle or toe fracture not x-rayed in the emergency department.

Upper limb fractures with follow-up by trust (2022/23)

Min

19.8 %

1st quartile

56.2 %

Median

65.1 %

3rd quartile

77.2 %

Max

98 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (46%) there would be an annual reduction in England of 13,768 (30.7%) follow-up appointments.

Min

25.9 %

1st quartile

74.2 %

Median

83.6 %

3rd quartile

90.4 %

Max

100 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (61.8%) there would be an annual reduction in England of 4,486 (25.8%) follow-up appointments.

Min

5.6 %

1st quartile

46.5 %

Median

61.2 %

3rd quartile

82.2 %

Max

97.4 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (31.4%) there would be an annual reduction in England of 4,440 (49.9%) follow-up appointments.

Lower limb fractures with follow-up by trust (2022/23)

Min

20.2 %

1st quartile

72.8 %

Median

83.7 %

3rd quartile

90.1 %

Max

100 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (60%) there would be an annual reduction in England of 2,817 (26.4%) follow-up appointments.

Min

11.1 %

1st quartile

31.7 %

Median

45.4 %

3rd quartile

56.9 %

Max

100 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (21.3%) there would be an annual reduction in England of 3,260 (53%) follow-up appointments.




Combining the potential reduction in the number of follow-up appointments for all of the fracture types included in this study, there could be a total annual reduction of 28,771 follow-up appointments in England.

This may be an underestimation as number of children may have more than one follow-up appointment that could be deemed unnecessary.

Cost of face-to-face follow-up appointments

For all fracture types the median cost of the first face-to-face outpatient attendance is £175. Prices are not available for virtual follow-up appointments, although the costs will be reduced compared to face-to-face appointments.

Number of clavicle fracture follow-ups by trust (2022/2023)


This includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.

There is significant variability between trusts in the number of follow-up appointments for clavicle fractures.

Differences between GIRFT/Model Hospital metric and our data

Firstly, there are some significant differences between the data included by GIRFT/Model Hospital and the data used in this study. GIRFT/Model Hospital:

  • include all forearm and wrist fractures, whereas we excluded certain fracture types, e.g open fractures which are assumed to all require treatment in theatre.

  • include re-manipulations in theatre, whilst we have excluded these.

  • use a 3-year average, whilst we used only the most recent year where follow-up data is available (2022/23).

The GIRFT/Model Hospital metric uses the total A&E attendances for those aged 16 and under as the denominator. Since, we find the fracture incidence rates vary by ICB region and the proportion of emergency department attendances for fractures vary by trust, we have used the number of each fracture type as the denominator, rather than the number of emergency department attendances.

Comparing methods for calculating the rate of manipulations

Graphs show our data for the number of forearm fractures manipulated in theatre in 2022/2023, but use different denominators to calculate the rate.

Top figure shows the 20 trusts with the highest (red) and 20 trusts with the lowest (green) rates of manipulations in theatre, according to the GIRFT/Model Hospital metric method of using total A&E attendances as the denominator.

Bottom figure uses the number of A&E attendances for forearm fractures as the denominator, and the same trusts labelled above are shown in their new positions according to this new metric. We have used this method to calculate manipulation rates in the subsequent slides.

Example 1, using total A&E attendances as the denominator The Royal Cornwall Hospitals Trust has a rate of ~16.6 forearm manipulations in theatre/10,000 A&E attendances, which puts it as the 11th highest rate in England. Using our metric with the number of forearm fractures as the denominator the manipulation rate of forearm fractures in theatre is 5.9%, moving The Royal Cornwall Hospitals Trust out of the highest quartile down to 43rd highest. This is unsurprising given the Cornwall ICB area has a high forearm fracture rate compared to many other regions.

Example 2, Chelsea and Westminster Hospital NHS Foundation trust has a rate of 1.3 forearm manipulations in theatre/10,000 A&E attendances, which is the 16th lowest rate in England. However, when the number of forearm fractures is used as the denominator the rate of forearm manipulations in theatre is 6%, suggesting the trust doesn’t actually perform as well as first thought moving it to the 42nd highest, with a similar rate to The Royal Cornwall Hospitals Trust.

Forearm fractures manipulated in theatre by trust (2022/23)

Min

0.2 %

1st quartile

2.3 %

Median

4.4 %

3rd quartile

6.5 %

Max

21.4 %

There could be an annual reduction in England of 1,747 (54.5 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2.3%).

Elbow fractures manipulated in theatre by trust (2022/23)

NOTE: Very low numbers at many providers

Min

0 %

1st quartile

0.5 %

Median

1.3 %

3rd quartile

2 %

Max

8.8 %

There could be an annual reduction in England of 177 (67%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%). This size of reduction is unlikely to have a significant impact in freeing up theatre time.

Cost of manipulations in the emergency department vs theatre

Forearm fractures

Elbow fractures


Those not manipulated in the emergency department are those that are manipulated but in theatre.

For both forearm and elbow fractures the median cost of an emergency care attendance when a fracture is manipulated in the emergency department £288 compared to a median cost of £184 when the fracture is not manipulated in emergency care, suggesting an increased cost of £104 for manipulating a fracture in the emergency department.

The median cost of manipulating a forearm fracture in theatre is £1,951 and the median cost for an elbow fracture is £2,231.

This suggests a cost saving of £1,847 for each forearm fracture and £2,127 for each elbow fracture manipulated in the emergency department, alongside the benefit of freeing up theatre time.

Sites from CRAFFT study (2023/24)

Manipulations of forearm fractures in theatre

  1. www.CRAFFTstudy.org


Trusts with hospitals participating in the CRAFFT study1 are shown in black; it can be seen that they are fairly evenly spread relative to other hospital sites, and aren’t clustered towards the lower end.

It show be noted that this chart is showing data from the most recent year, 2023-24, rather than 2022/23 which was used for the previous analysis as it ensured we have the full 3-month follow-up period.

Summary of the potential activity reductions

  • A reduction in x-rays in emergency care for clavicle and toe fractures in trusts down to the level of the lowest decile of trusts would reduce the number of x-rays in emergency care in England by around 4,400 per year.

  • A reduction in follow-up appointments for the fracture types studied here down to the level of the lowest decile of trusts would reduce the number of follow-up appointments in England by at least 28,800 per year. This is based on reducing the number of first follow-ups, it is likely that a number of children have more than one unnecessary follow-up so this is likely an underestimate of the potential savings.

  • A reduction in the number of forearm and elbow fractures manipulated in theatre down to the level of the lowest quartile would reduce the number of manipulations in theatre in England by 1,900 a year.

  • The number of manipulations in theatre and total number of manipulations, especially for forearm fractures, have significantly decreased over the last 6 years, suggesting previous studies and changes in guidance are having an impact on manipulations. Obviously, some trusts have already implemented more conservative management approaches to paediatric fractures, but there are likely some trusts that could still significantly benefit from adopting this approach.

  • While there has been significant progress in reducing the total number of manipulations and proportion of manipulations in theatre, especially for forearm fractures, there is perhaps also scope to work on reducing the number of fractured clavicles and toes which are x-rayed and in reducing unnecessary follow up appointments.

  • These potential reductions in activity are for England only, there is likely also the potential for activity savings in the other countries of the UK.

Limitations

We are relying on the coding/reporting of fractures and subsequent activity within the the SUS datasets. Some of the variability in the number of fractures, x-rays, physiotherapy referrals, follow-up appointments and manipulations in both theatre and the emergency department could be due to issues with the coding. It is possible some of our numbers may be underestimates due to some activity potentially not being accurately coded, or reported.

It should be noted that our incidence rates for fractures are only for closed fractures, open fractures were excluded and thus to total incidence rates if including all types of fractures would be higher.

The coding of fractures is not specific enough to determine at an individual level which fractures could be managed more conservatively, so we are relying on comparing proportion between trusts. Some fractures will be more complex and require manipulation and follow-up, but we can’t be sure whether all trusts have a similar proportion of more complex fractures.

Only closed manipulations without internal fixation are included in our data, so if some trusts are treating a higher proportion of fractures with internal fixation then their rate of closed manipulations could appear lower. We have also not included re-manipulations in our data.

There will be a small number of cases where a child has more than one fracture or other injuries (<1%), so although have may have classified the fracture as a certain type any follow-up appointments or manipulations could potentially be for a different injury/fracture sustained at the same time.

It should be noted is that data is allocated to the trust where the child attended the emergency department; if a child first attended the emergency department at trust A while on holiday but subsequently received follow-up appointments at trust B once they returned home the fracture and subsequent follow-up would be included in the data for trust A.

The number of elbow manipulations recorded in theatre appears lower than would be expected, which may be due to coding issues. The lack of specific coding of fractures makes it difficult to determine what is an elbow fracture and may mean that some are classified as forearm fractures, e.g. the SNOMED code for ‘Closed fracture of radius (disorder)’ is the most commonly used, and while we have classified these as forearm fractures, fractures of the proximal radius would be considered an elbow fracture. This may in part explain why we see a smaller number of elbow manipulations in theatre than would be expected, as they are included within forearm fractures. Also, HRG groupings for manipulations in theatre do not distinguish between forearm and elbow procedures, so it is not possible to determine from these which are forearm and which are elbow.

Discussion

As highlighted within the Paediatric Trauma and Orthopaedic Surgery GIRFT report there are a number of factors that may be reduce the proportion of manipulations in the emergency department, including concerns about breach times, a lack of space/facilities to perform sedation, and a lack of familiarity with techniques1. Concerns around litigation may also lead to less conservative management, especially with elbow fractures which can lead to rare, but severe, complications. It is possible factors related to culture, lack of experience and litigation may also influence conservative management when it comes to reducing x-rays for clavicle and toe fractures and reducing follow-up appointments.

Nottingham University Hospitals NHS Trust, who are known to utilise more conservative management of paediatric fractures including routinely manipulating forearm fractures in the emergency department1,2, have as expected one of the lowest proportions of forearm fractures manipulated in theatre. In 2022/2023 only 0.5% of forearm fractures were manipulated in theatre (while 11.81% were manipulated in the emergency department) meaning only 4% of all forearm fractures requiring manipulation were performed in theatre. In terms of follow-up appointments 57% of forearm fractures receive a follow-up appointment, which is just above the lowest quartile.

In the Paediatric Trauma and Orthopaedic Surgery GIRFT report it was suggested that there was scope to reduce the number of paediatric forearm manipulations in theatre by 80%1. That study used data from 2016-2019, in our study we have found since 2018/2019 the proportion of forearm fractures manipulated in theatre has fallen by almost 60%, from 9% in 2018/19 to under 4% in 2023/24.

It appears that there is the possibility to further reduce manipulations in theatre, particularly at some trusts, but overall at a national level the decrease is likely to start slowing as smaller numbers of fractures are manipulated in theatre. There is perhaps more scope in the future to reduce activity in terms of reducing unnecessary x-rays in the emergency department for clavicle and toe fractures and in reducing the number of follow-up appointments. The total number of forearm fractures that are manipulated has been decreasing, and there is perhaps scope for this to decrease further. Indeed, the CRAFFT study being conducted at over 45 sites in England is investigating whether there are any differences in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children3.

The GIRFT report found some trusts have moved towards splinting fractures in the emergency department with a virtual follow-up, rather than a temporary cast and then referral to a fracture clinic1. From our data the use of virtual follow-ups appears widespread, but there may be scope to reduce virtual appointments, especially as some trusts with high overall follow-up rates have a particularly high number of virtual appointments.

  1. Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
  2. Bryson D et al. (2016) The lost art of conservative management of paediatric fractures. Bone Joint 360. 5(1):2-8.
  3. https://crafft-study.digitrial.com/

Future work

It may be helpful to do some more detailed mapping and analysis of patient pathways to better understand how fractures are being managed, and where further activities savings could be made with more conservative management.

There are currently trends towards more conservative management, particularly regarding increasing manipulations in the emergency department, and also towards greater use of urgent treatment centres, so there is further scope to investigate how this may play out in the future, including the extent to which these trends can continue and further activity can be reduced.

Appendix A- Forearm and Clavicle fracture SNOMED codes

Forearm

208388003

Fracture at wrist and/or hand level (disorder)

209264008

Closed fracture dislocation of wrist (disorder)

209265009

Closed fracture dislocation distal radioulnar joint (disorder)

209284007

Closed fracture subluxation of distal radioulnar joint (disorder)

67730008

Closed Bennett's fracture (disorder)

307713000

Closed Barton's fracture (disorder)

208324004

Closed dorsal Barton's fracture (disorder)

208323005

Closed volar Barton's fracture (disorder)

209283001

Closed fracture subluxation of the wrist (disorder)

263102004

Fracture subluxation of wrist (disorder)

61653009

Bennett's fracture (disorder)

263103009

Fracture subluxation of distal radioulnar joint (disorder)

1290784005

Stress fracture of bone of wrist region (disorder)

1303397005

Fracture of bone of wrist region (disorder)

1285722006

Fracture of distal end of left ulna (disorder)

14430001000004100

Fracture of distal end of right ulna (disorder)

27094009

Skillern's fracture (disorder)

281530009

Fracture of ulnar styloid (disorder)

41036008

Closed fracture of styloid process of ulna (disorder)

263208005

Fracture of distal end of radius and ulna (disorder)

33192001

Closed fracture of lower end of radius AND ulna (disorder)

50397009

Closed fracture of distal end of ulna (disorder)

208318005

Closed fracture of ulna, lower epiphysis (disorder)

6163002

Closed fracture of head of ulna (disorder)

263199001

Fracture of distal end of radius (disorder)

58722007

Moore's fracture (disorder)

448355005

Greenstick fracture of distal radius (disorder)

737262009

Fracture of lower end of radius with volar tilt (disorder)

737261002

Fracture of lower end of radius with dorsal tilt (disorder)

123972004

Reversed Colles' fracture (disorder)

123618009

Closed reverse Colles' fracture (disorder)

281527002

Fracture of radial styloid (disorder)

208325003

Closed fracture radial styloid (disorder)

426467005

Hutchinson's fracture (disorder)

18310001000004100

Fracture of distal end of right radius (disorder)

16542901000119100

Closed fracture of metaphysis of distal end of right radius (disorder)

1285724007

Fracture of distal end of left radius (disorder)

16542861000119100

Closed fracture of metaphysis of distal end of left radius (disorder)

123971006

Colles' fracture (disorder)

269083002

Closed Colles' fracture (disorder)

17222009

Closed fracture of distal end of radius (disorder)

448838000

Closed extraarticular fracture of distal radius (disorder)

208326002

Closed fracture distal radius, intra-articular, die-punch (disorder)

704212006

Closed fracture of distal epiphysis of radius (disorder)

1279881008

Closed fracture of metaphysis of distal end of radius (disorder)

35442005

Closed fracture of lower end of forearm (disorder)


307172007

Fracture dislocation distal radioulnar joint (disorder)

1264544004

Fracture of bone adjacent to prosthesis of wrist joint (disorder)

12217801000119100

Fracture of bone adjacent to prosthesis of left wrist joint (disorder)

12202711000119100

Fracture of bone adjacent to prosthesis of right wrist joint (disorder)

1303394003

Fracture of bone of left wrist region (disorder)

1303396001

Fracture of bone of bilateral wrist regions (disorder)

1303395002

Fracture of bone of right wrist region (disorder)

46773004

Quervain's fracture (disorder)

3228009

Closed fracture of shaft of radius (disorder)

12676007

Fracture of radius (disorder)

28078000

Closed fracture of shaft of bone of forearm (disorder)

53627009

Closed fracture of radius AND ulna (disorder)

53792000

Closed fracture of shaft of ulna (disorder)

54556006

Fracture of ulna (disorder)

54645004

Barton's fracture (disorder)

54819005

Closed fracture of shaft of radius and ulna (disorder)

65966004

Fracture of forearm (disorder)

71555008

Closed fracture of ulna (disorder)

75857000

Fracture of radius AND ulna (disorder)

91419009

Closed fracture of forearm (disorder)

111640008

Closed fracture of radius (disorder)

208309008

Closed fracture radius and ulna, middle (disorder)

208322000

Closed Galeazzi fracture (disorder)

208513000

Multiple fractures of forearm (disorder)

263198009

Fracture of shaft of radius (disorder)

263200003

Volar Barton's fracture (disorder)

263201004

Dorsal Barton's fracture (disorder)

263204007

Fracture of shaft of ulna (disorder)

263205008

Fracture of distal end of ulna (disorder)

263207000

Fracture of shaft of radius and/or ulna (disorder)

268824003

Fracture of radius and/or ulna due to birth trauma (disorder)

271576001

Galeazzi fracture dislocation (disorder)

281528007

Fracture of olecranon (disorder)

281529004

Fracture of coronoid process of ulna (disorder)

287074009

Fracture malunion - forearm (disorder)

390986009

Torus fracture of radius (disorder)

429655000

Closed torus fracture of radius (disorder)

704056001

Stress fracture of ulna (disorder)

704059008

Stress fracture of radius (disorder)

733235002

Fracture of shaft of ulna and radius (disorder)

1285721004

Fracture of right ulna (disorder)

1303390007

Fracture of bone of left forearm (disorder)

1303391006

Fracture of bone of right forearm (disorder)

446461000124103

Fracture of right radius (disorder)

12960001000004100

Fracture of left radius (disorder)

13270001000004100

Fracture of left ulna (disorder)

Clavicle

58150001

Fracture of clavicle

33173003

Closed fracture of clavicle

1658003

Closed fracture of acromial end of clavicle

87376003

Closed fracture of shaft of clavicle

48561006

Closed fracture of sternal end of clavicle

88196000

Fracture of interligamentous part of clavicle (disorder)

1303380004

Fracture of left clavicle (disorder)

1303379002

Fracture of bone of bilateral clavicles (disorder)

1303381000

Fracture of right clavicle (disorder)

41972004

Fracture of shaft of clavicle (disorder)

56642004

Fracture of sternal end of clavicle (disorder) 

733403004

Multiple fractures of clavicle (disorder)

208510002

Multiple fractures of clavicle, scapula and humerus (disorder)

431011000

Nonunion of fracture of clavicle (disorder)

704069002

Stress fracture of clavicle (disorder) 

Appendix B- Elbow fracture SNOMED codes


123973009

Monteggia's fracture (disorder)

1303382007

Fracture of left olecranon (disorder)

1303383002

Fracture of right olecranon (disorder)

1303392004

Fracture of bone of left elbow joint region (disorder)

1303393009

Fracture of bone of right elbow joint region (disorder)

16866431000119100

Closed fracture of capitellum of right humerus (disorder)

16867081000119100

Closed fracture of capitellum of left humerus (disorder)

19259001

Closed fracture of upper end of radius AND ulna (disorder)

208267005

Closed fracture distal humerus, lateral condyle (disorder)

208270009

Closed fracture of distal humerus, trochlea (disorder)

208271008

Closed fracture distal humerus, lateral epicondyle (disorder)

208272001

Closed fracture distal humerus, capitellum (disorder)

208273006

Closed fracture distal humerus, bicondylar (T-Y fracture) (disorder)

208274000

Multiple closed fractures of distal humerus (disorder)

208294009

Closed fracture olecranon, extra-articular (disorder)

208295005

Closed fracture of proximal ulna, comminuted (disorder)

208296006

Closed fracture proximal radius, comminuted (disorder)

208298007

Closed fracture olecranon, intra-articular (disorder)

209252000

Closed fracture dislocation elbow joint (disorder)

209253005

Closed fracture dislocation superior radioulnar joint (disorder)

209258001

Closed fracture subluxation of elbow joint (disorder)

209259009

Closed fracture subluxation superior radioulnar joint (disorder)

21419000

Closed fracture of medial condyle of humerus (disorder)

2295008

Closed fracture of upper end of forearm (disorder)

263078002

Fracture dislocation of elbow joint (disorder)

263100007

Fracture subluxation of elbow joint (disorder)

263101006

Fracture subluxation of superior radioulnar joint (disorder)

263192005

Fracture of distal end of humerus (disorder)

263193000

Supracondylar fracture of humerus (disorder)

263195007

Fracture of proximal end of radius (disorder)


263196008

Fracture of radial head (disorder)

263197004

Fracture of radial neck (disorder)

263203001

Fracture of proximal end of ulna (disorder)

263206009

Fracture of proximal end of radius and ulna (disorder)

269080004

Closed fracture of the distal humerus (disorder)

281525005

Fracture of the lateral humeral epicondyle (disorder)

281526006

Fracture of the medial humeral epicondyle (disorder)

29045004

Closed Monteggia's fracture (disorder)

302222008

Elbow fracture - closed (disorder)

309464009

Elbow fracture (disorder) 

33041006

Closed fracture of proximal end of ulna (disorder)

440366004

Closed fracture of the medial epicondyle of humerus (disorder)

441496000

Transcondylar fracture of distal humerus (disorder)

442448003

Fracture of head of radius with dislocation of distal radioulnar joint and interosseous membrane disruption (disorder)

58580000

Closed supracondylar fracture of humerus (disorder)

5895007

Closed multiple fractures of upper end of radius (disorder)

64902007

Closed fracture of olecranon process of ulna (disorder)

68819003

Closed fracture of coronoid process of ulna (disorder)

68854005

Closed fracture of head of radius (disorder)

700147004

Avulsion fracture of medial epicondyle of humerus (disorder)

704208000

Closed fracture of proximal epiphysis of radius (disorder)

704410001

Closed transcondylar fracture of distal humerus (disorder)

705076001

Closed fracture of epiphyseal plate of distal humerus (disorder)

71139009

Closed fracture of proximal end of radius (disorder)

72497001

Closed fracture of neck of radius (disorder)

733408008

Fracture of lateral condyle of humerus (disorder)

733409000

Fracture of medial condyle of humerus (disorder)

7341005

Closed multiple fractures of upper end of ulna (disorder)

80767005

Closed fracture of condyle of humerus (disorder)

Appendix C- Tibia/Fibula and Toe fracture SNOMED codes

Tibia/Fibula

31978002

Fracture of tibia (disorder)

6698000

Closed trimalleolar fracture (disorder)

6990005

Fracture of shaft of tibia (disorder)

15385006

Closed fracture of medial malleolus (disorder)

20433007

Fracture of upper end of tibia (disorder)

23900009

Closed fracture of upper end of tibia (disorder)

25899002

Closed bimalleolar fracture (disorder)

28012007

Closed fracture of shaft of tibia (disorder)

47848000

Closed fracture of condyle of tibia (disorder)

71830006

Supination-adduction injury of ankle, stage 2 (disorder)

87905008

Gosselin's fracture (disorder)

123975002

Trimalleolar fracture (disorder)

208610006

Closed fracture proximal tibia, medial condyle (plateau) (disorder)

208611005

Closed fracture proximal tibia, lateral condyle (plateau) (disorder)

208612003

Closed fracture proximal tibia, bicondylar (disorder)

208613008

Closed fracture intercondylar spine of tibia (disorder)

208629000

Closed fracture of tibia and fibula, shaft (disorder)

208634001

Closed fracture distal tibia (disorder)

208635000

Closed fracture distal tibia, extra-articular (disorder)

208636004

Closed fracture distal tibia, intra-articular (disorder)

208662008

Closed fracture ankle, bimalleolar, low fibular fracture (disorder)

208663003

Closed fracture ankle, bimalleolar, high fibular fracture (disorder)

208666006

Closed fracture ankle, trimalleolar, low fibular fracture (disorder)

208667002

Closed fracture ankle, trimalleolar, high fibular fracture (disorder)

263237009

Closed fracture of tibial tuberosity (disorder)

263240009

Pilon fracture (disorder)

263241008

Tillaux fracture (disorder)

263244000

Bimalleolar fracture of ankle (disorder)

271577005

Fracture of shaft of tibia and fibula (disorder)

278537006

Fracture of distal end of tibia (disorder)

281531008

Fracture of medial malleolus (disorder)

281532001

Fracture of posterior malleolus (disorder)

281843000

Fracture of tibial spine (disorder)

413877007

Closed fracture of tibia AND fibula (disorder)

414293001

Fracture of tibia AND fibula (disorder)

428256003

Fracture of condyle of tibia (disorder)

428257007

Fracture of tibial plateau (disorder)

428797006

Closed osteochondral fracture of proximal tibia (disorder)

428798001

Closed fracture of tibial plateau (disorder)

442205007

Stress fracture of tibia (disorder)

445410003

Closed fracture of distal tibia and distal fibula (disorder)

446298003

Closed pilon fracture (disorder)

447139008

Closed fracture of tibia (disorder)

703998005

Closed bicondylar fracture of tibial plateau (disorder)


705080006

Closed fracture of epiphyseal plate of distal tibia (disorder)

705092006

Closed fracture of epiphyseal plate of proximal tibia (disorder)

733295004

Avulsion of tibial tuberosity (disorder)

735669008

Fracture of metaphysis of proximal tibia (disorder)

735671008

Fracture of lateral condyle of tibia (disorder)

735672001

Fracture of medial condyle of tibia (disorder)

735846008

Avulsion of ligament with bony fragment of medial malleolus (disorder)

39541000087106

Fracture of medial condyle of left tibia (disorder)

39551000087109

Fracture of medial condyle of right tibia (disorder)

40031000087104

Fracture of left tibial plateau (disorder)

40041000087105

Fracture of right tibial plateau (disorder)

40051000087108

Fracture of lateral condyle of left tibia (disorder)

40061000087106

Fracture of lateral condyle of right tibia (disorder)

40071000087102

Fracture of left medial malleolus (disorder)

40081000087100

Fracture of right medial malleolus (disorder)

10924841000119100

Closed fracture of medial condyle of right tibia (disorder)

10924881000119100

Closed fracture of medial condyle of left tibia (disorder)

75591007

Fracture of fibula (disorder)

21867001

Fracture of upper end of fibula (disorder)

28359007

Closed fracture of head of fibula (disorder)

34268009

Closed fracture of lateral malleolus (disorder)

59639009

Closed fracture of upper end of fibula (disorder)

67394003

Fracture of shaft of fibula (disorder)

77803008

Closed fracture of shaft of fibula (disorder)

208615001

Closed fracture fibula, neck (disorder)

208657007

Closed fracture ankle, lateral malleolus, low (disorder)

208658002

Closed fracture ankle, lateral malleolus, high (disorder)

263242001

Fracture of distal end of fibula (disorder)

281533006

Fracture of head of fibula (disorder)

281534000

Fracture of neck of fibula (disorder)

281535004

Fracture of lateral malleolus (disorder)

308153009

Closed fracture of distal fibula (disorder)

315643003

Dupuytren's fracture dislocation ankle (disorder)

442538002

Stress fracture of fibula (disorder)

447395005

Closed fracture of fibula (disorder)

704209008

Closed fracture of epiphysis of proximal fibula (disorder)

705082003

Closed fracture of epiphyseal plate of distal fibula (disorder)

733296003

Avulsion of head of fibula (disorder)

735842005

Fracture of lateral malleolus below syndesmosis (disorder)

735844006

Avulsion of ligament with bony fragment of lateral malleolus (disorder)

735845007

Fracture of lateral malleolus at syndesmosis (disorder)

735847004

Fracture of distal fibula above syndesmosis (disorder)

736517000

Avulsion fracture of anterior fibula (disorder)

19350001000004100

Stress fracture of tibia and fibula (disorder)

Toe

21351003

Fracture of phalanx of foot (disorder) 

81576005

Closed fracture of phalanx of foot (disorder)

302036006

Closed fracture dislocation of interphalangeal joint of toe (disorder)

209361003

Closed fracture dislocation of interphalangeal joint of multiple toes (disorder)

209378007

Closed fracture subluxation of interphalangeal joint of multiple toes (disorder)

209359007

Closed fracture dislocation of interphalangeal joint of single toe (disorder)

208712008

Closed fracture distal phalanx, toe (disorder)

705067008

Closed fracture of distal phalanx of lesser toe (disorder)

208711001

Closed fracture middle phalanx, toe (disorder)

705068003

Closed fracture of epiphyseal plate of lesser toe (disorder)

208713003

Closed fracture of multiple phalanges of toe (disorder)

208710000

Closed fracture proximal phalanx, toe (disorder)

704057005

Stress fracture of phalanx of foot (disorder)

11314801000119100

Stress fracture of phalanx of left foot (disorder) 

11314761000119100

Stress fracture of phalanx of right foot (disorder)

263093003

Fracture dislocation of toe joint (disorder)

263117000

Fracture subluxation of interphalangeal joint of toe (disorder)

209375005

Closed fracture subluxation of interphalangeal joint of single toe (disorder)



Appendix D

Manipulation in emergency department identified using A&E Treatment Code:

10- Reduction

Manipulation in theatre was identified by one of the following OPCS codes recorded during an inpatient episode in the 3 months post-emergency care attendance.

  • W262 Manipulation of fracture of bone NEC
  • W268 Other specified
  • W269 Unspecified
  • W663 Primary manipulative closed reduction of fracture dislocation of joint NEC
  • W252 Closed reduction of fracture of bone and fixation using functional bracing system

X-ray in the emergency department was identified using A&E Investigation Code:

01- X-ray

Physiotherapy appointments were identified by one of the following:

  • SNOMED referral code for physiotherapy in ECDS- 306170007 Referral to physiotherapy service (procedure)
  • Treatment Function Code for physiotherapy in the outpatient dataset in the 3 months post-emergency care attendance- 650 Physiotherapy Service

Outpatient follow up appointments were identified using the following codes in the outpatient dataset in the 3 months post-emergency care attendance

Treatment function code was one of:

  • 110 Trauma and Orthopaedic service
  • 111 Orthopaedic Service
  • 115 Trauma Surgery Service
  • 214 Paediatric Trauma and Orthopaedic Service

Or 420 Paediatrics provided that the outpatient referral source was either: 10- initiated following an emergency care attendance (including minor injuries, walk in centres and urgent treatment centres) OR 04- not initiated following a referral from an emergency care department (including minor injuries, walk in centres and urgent treatment centres)

It was also required that the emergency care attendance discharge information did NOT have the SNOMED code- 3780001 Routine patient disposition, no follow-up planned (procedure)